Psychometric properties of the Diabetes Eating Problem Survey-Revised among Dutch adults with type 1 diabetes and implications for clinical use

AIMS

Disordered eating behaviour (DEB) in people with type 1 diabetes (T1D) can be screened with the Diabetes Eating Problem Survey-Revised (DEPS-R). This study aimed to investigate the psychometric properties of the DEPS-R among Dutch adults with T1D and to explore the individual items alongside the standard cut-off score of ≥20 for clinical use.

METHODS

The construct validity of the DEPS-R was assessed with an exploratory factor analysis, through principal axis factoring and with Spearman correlations between clinical variables and the DEPS-R. Backward logistic regression identified clinical predictors for DEPS-R scores above the cut-off. DEPS-R item responses were summarized with frequencies, means and standard deviations.

RESULTS

Participants were 145 adults with T1D, of whom 79.3% were women and 35.9% presented with DEB based on the cut-off. A single-factor solution of the DEPS-R showed good internal consistency, while a three-factor solution showed acceptable to good internal consistency within the factors. A younger age, a higher BMI and more diabetes distress were predictors for a DEPS-R cut-off score of ≥20. Clinically relevant items were identified that contributed minimally to the DEPS-R score.

CONCLUSIONS

This study supports a single-factor and a three-factor structure of the DEPS-R while also suggesting an item-specific or factor-specific approach in clinical practice.

A Self-Guided Web-Based App (MyDiaMate) for Enhancing Mental Health in Adults With Type 1 Diabetes: Insights From a Real-World Study in the Netherlands

BACKGROUND

MyDiaMate is a web-based intervention specifically designed for adults with type 1 diabetes (T1D) that aims to help them improve and maintain their mental health. Prior pilot-testing of MyDiaMate verified its acceptability, feasibility, and usability.

OBJECTIVE

This study aimed to investigate the real-world uptake and usage of MyDiaMate in the Netherlands.

METHODS

Between March 2021 and December 2022, MyDiaMate was made freely available to Dutch adults with T1D. Usage (participation and completion rates of the modules) was tracked using log data. Users could volunteer to participate in the user profile study, which required filling out a set of baseline questionnaires. The usage of study participants was examined separately for participants scoring above and below the cutoffs of the "Problem Areas in Diabetes" (PAID-11) questionnaire (diabetes distress), the "World Health Organization Well-being Index" (WHO-5) questionnaire (emotional well-being), and the fatigue severity subscale of the "Checklist Individual Strength" (CIS) questionnaire (fatigue). Two months after creating an account, study participants received an evaluation questionnaire to provide us with feedback.

RESULTS

In total, 1008 adults created a MyDiaMate account, of whom 343 (34%) participated in the user profile study. The mean age was 43 (SD 14.9; 18-76) years. Most participants were female (n=217, 63.3%) and higher educated (n=198, 57.6%). The majority had been living with T1D for over 5 years (n=241, 73.5%). Of the study participants, 59.1% (n=199) of them reported low emotional well-being (WHO-5 score≤50), 70.9% (n=239) of them reported elevated diabetes distress (PAID-11 score≥18), and 52.4% (n=178) of them reported severe fatigue (CIS score≥35). Participation rates varied between 9.5% (n=19) for social environment to 100% (n=726) for diabetes in balance, which opened by default. Completion rates ranged from 4.3% (n=1) for energy, an extensive cognitive behavioral therapy module, to 68.6% (n=24) for the shorter module on hypos. There were no differences in terms of participation and completion rates of the modules between study participants with a more severe profile, that is, lower emotional well-being, greater diabetes distress, or more fatigue symptoms, and those with a less severe profile. Further, no technical problems were reported, and various suggestions were made by study participants to improve the application, suggesting a need for more personalization.

CONCLUSIONS

Data from this naturalistic study demonstrated the potential of MyDiaMate as a self-help tool for adults with T1D, supplementary to ongoing diabetes care, to improve healthy coping with diabetes and mental health. Future research is needed to explore engagement strategies and test the efficacy of MyDiaMate in a randomized controlled trial.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Observing, 'doing' and 'making' gender in Dutch paediatric type 1 diabetes care, at home and in the clinic: Multiple-stakeholder perspectives

AIM

To investigate the perspectives of Dutch care professionals, parents and experts by experience on gender dynamics in paediatric type 1 diabetes care.

DESIGN

Qualitative research design.

METHODS

Fifteen semi-structured interviews were held with care professionals, supplemented by two focus groups with parents of children with diabetes (n = 12 parents) and three semi-structured interviews with two experts by experience and a mother. Two respondent validation interviews were conducted, one with two care professionals and one with an expert by experience. Participant observations were conducted at three clinics, a diabetes sports day, weekend for young people and their families, and a high-school. An inductive framework analysis was done, informed by relational theory on gender.

RESULTS

Care professionals 'did' and 'made' gender differences together with young people, manifesting as communicative difficulties, in particular between female care professionals and young boys. Boys were considered less skilled in articulating their needs compared to girls. At home, care professionals and parents observed, 'did' and 'made' gender differences by perpetuating gendered divisions of labour. As traditional caretakers, mothers risk focusing excessively on the diabetes of their child whilst fathers remained more at a distance.

CONCLUSION

Gender patterns have negative implications on those involved in paediatric type 1 diabetes. Leaving tacit the gendered communicative issues across child-parent and child-care professional dyads, can sustain invisible friction in a care system that normatively expects verbal participation and increased self-management.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Findings may encourage care professionals and parents to engage with the potential impact of gender dynamics on diabetes practices. Incorporating these dynamics as conversational tools would contribute to improving type 1 diabetes care for young people.

Glucose variability and mood in people with type 1 diabetes using ecological momentary assessment

OBJECTIVE

Mood fluctuations related to blood glucose excursions are a commonly reported source of diabetes-distress, but research is scarce. We aimed to assess the relationship between real-time glucose variability and mood in adults with type 1 diabetes (T1D) using ecological momentary assessments.

METHODS

In this prospective observational study, participants wore a masked continuous glucose monitor and received prompts on their smartphone 6 times a day to answer questions about their current mood (Profile Of Mood States (POMS)-SF (dimensions: Anxiety, Depressive symptoms, Anger, Fatigue, Vigor)) for 14 days. Mixed model analyses examined associations over time between daily Coefficient of Variation (CV) of blood glucose and mean and variability (CV) of POMS scores. Further, within-person differences in sleep and nocturnal hypoglycemia were explored.

RESULTS

18 people with T1D (10 female, mean age 44.3 years) participated. A total of 264 out of 367 days (70.2%) could be included in the analyses. No overall significant associations were found between CV of blood glucose and mean and CV of POMS scores, however, nocturnal hypoglycemia moderated the associations between CV of blood glucose and POMS scales (mean Fatigue Estimate 1.998, p < .006, mean Vigor Estimate -3.308, p < .001; CV Anger Estimate 0.731p = 0.02, CV Vigor Estimate -0.525, p = .006).

CONCLUSION

We found no overall relationship between real-time glycemic variability and mood per day. Further research into within-person differences such as sleep and nocturnal hypoglycemia is warranted.

Associations between disordered eating behaviour, diabetes distress and emotion regulation strategies in adults with type 1 diabetes: results from a Dutch-Italian cross-sectional study

AIMS

Disordered eating behaviour (DEB) and diabetes distress are prevalent in adults with type 1 diabetes (T1D). Emotion regulation strategies, such as cognitive reappraisal and expressive suppression, are associated with DEB and managing stress in general. Here we examine the associations between DEB, diabetes distress, and emotion regulation strategies in the context of T1D.

METHODS

Adults with T1D in The Netherlands and Italy completed an online survey, covering DEB (DEPS-R), diabetes distress (PAID-5), and emotion regulation strategies (ERQ). Associations between DEB, diabetes distress, and emotion regulation strategies were examined using path analysis.

RESULTS

N = 291 participants completed the survey (78.9% women, 39±13 years, HbA1c: 55±16 mmol/mol (7.2% (3.6%)); TIR: 66%±25). N = 79 participants (27.1%) reported DEB (DEPS-R≥20) and n = 159 participants (54.6%) reported elevated diabetes distress (PAID-5≥8). The path analysis, with small-to-medium effect sizes, revealed that higher diabetes distress was associated with more DEB (β = .23, 95% CI [.13, .34]). Lower diabetes distress was associated with more use of cognitive reappraisal (β = -.24, 95% CI [-.36, -.12]). More DEB was associated with more use of expressive suppression (β = .14, 95% CI [.04, .24]).

CONCLUSIONS

This cross-sectional study suggests an association between DEB and diabetes distress, between cognitive reappraisal and less diabetes distress and between expressive suppression and more DEB. The results suggest that it may prove beneficial to prioritize strengthening emotion regulation strategies in interventions for people with T1D and DEB. Future research should help clarify causality with regard to emotion regulation and DEB in adults with T1D.

Improved Effectiveness of Immediate Continuous Glucose Monitoring in Hypoglycemia-Prone People with Type 1 Diabetes Compared with Hypoglycemia-Focused Psychoeducation Following a Previous Structured Education: A Randomized Controlled Trial

Objective: Stepped-care has been suggested in the management of patients with problematic hypoglycemia and impaired awareness of hypoglycemia (IAH), initially with psychoeducational programs based on blood glucose awareness training, progressing to diabetes technology in those with persisting need. We examined the clinical effectiveness of stepped-care starting with HypoAware and adding continuous glucose monitoring (CGM) as needed, versus immediate CGM in type 1 diabetes patients with problematic hypoglycemia despite previous structured education in insulin adjustment. Research Design and Methods: A randomized controlled trial (N = 52, mean age 53, 56% females). The stepped-care group attended HypoAware. If a severe hypoglycemic event (SHE) had occurred or IAH was still present after 6 months, CGM was initiated. The control group started immediate CGM. Primary endpoint was the number of participants with self-reported SHE. Secondary outcomes, evaluated at 6 and 12 months, were glycated hemoglobin (HbA1c), the number of participants with IAH time below range (TBR; <54 mg/dL), and patient-reported outcomes (PROs). Results: At 6 months, the number of patients reporting SHE had decreased significantly more in the CGM group: -39% (P < 0.05). HbA1c decreased more in the CGM group (-0.47 percentage-points, P < 0.05). IAH was restored in 31% of patients in both groups. TBR (<54 mg/dL) was lower in the CGM group (-2.4 percentage-points, P < 0.05). In the stepped-care group, 93% started CGM/intermittently scanned CGM. At 12 months, the number of patients reporting SHE was still higher in the stepped-care group. No differences were found in PROs. Conclusions: Immediate start of CGM is more effective than a hypoglycemia-focused reeducation program in reducing SHE risk and attaining glycemic targets in individuals with problematic hypoglycemia and IAH despite previous education in insulin dose adjustment. Trial registration: Netherlands Trial Register, NL64474.029.18.

The role of mental disorders in precision medicine for diabetes: a narrative review

This narrative review aims to examine the value of addressing mental disorders as part of the care of people with type 1 and type 2 diabetes in terms of four components of precision medicine. First, we review the empirical literature on the role of common mental disorders in the development and outcomes of diabetes (precision prevention and prognostics). We then review interventions that can address mental disorders in individuals with diabetes or at risk of diabetes (precision treatment) and highlight recent studies that have used novel methods to individualise interventions, in person and through applications, based on mental disorders. Additionally, we discuss the use of detailed assessment of mental disorders using, for example, mobile health technologies (precision monitoring). Finally, we discuss future directions in research and practice and challenges to addressing mental disorders as a factor in precision medicine for diabetes. This review shows that several mental disorders are associated with a higher risk of type 2 diabetes and its complications, while there is suggestive evidence indicating that treating some mental disorders could contribute to the prevention of diabetes and improve diabetes outcomes. Using technologically enabled solutions to identify mental disorders could help individuals who stand to benefit from particular treatments. However, there are considerable gaps in knowledge and several challenges to be met before we can stratify treatment recommendations based on mental disorders. Overall, this review demonstrates that addressing mental disorders as a facet of precision medicine could have considerable value for routine diabetes care and has the potential to improve diabetes outcomes.

The handling of missing data in trial-based economic evaluations: should data be multiply imputed prior to longitudinal linear mixed-model analyses?

INTRODUCTION

For the analysis of clinical effects, multiple imputation (MI) of missing data were shown to be unnecessary when using longitudinal linear mixed-models (LLM). It remains unclear whether this also applies to trial-based economic evaluations. Therefore, this study aimed to assess whether MI is required prior to LLM when analyzing longitudinal cost and effect data.

METHODS

Two-thousand complete datasets were simulated containing five time points. Incomplete datasets were generated with 10, 25, and 50% missing data in follow-up costs and effects, assuming a Missing At Random (MAR) mechanism. Six different strategies were compared using empirical bias (EB), root-mean-squared error (RMSE), and coverage rate (CR). These strategies were: LLM alone (LLM) and MI with LLM (MI-LLM), and, as reference strategies, mean imputation with LLM (M-LLM), seemingly unrelated regression alone (SUR-CCA), MI with SUR (MI-SUR), and mean imputation with SUR (M-SUR).

RESULTS

For costs and effects, LLM, MI-LLM, and MI-SUR performed better than M-LLM, SUR-CCA, and M-SUR, with smaller EBs and RMSEs as well as CRs closers to nominal levels. However, even though LLM, MI-LLM and MI-SUR performed equally well for effects, MI-LLM and MI-SUR were found to perform better than LLM for costs at 10 and 25% missing data. At 50% missing data, all strategies resulted in relatively high EBs and RMSEs for costs.

CONCLUSION

LLM should be combined with MI when analyzing trial-based economic evaluation data. MI-SUR is more efficient and can also be used, but then an average intervention effect over time cannot be estimated.

A personalised intervention programme aimed at improving adherence to oral antidiabetic and/or antihypertensive medication in people with type 2 diabetes mellitus, the INTENSE study: study protocol for a randomised controlled trial

BACKGROUND

Medication non-adherence is a prevalent health problem in people with type 2 diabetes mellitus (T2DM). Interventions have previously been developed to improve medication adherence, but inconsistent outcomes have been reported. A potential explanation for this inconsistency is a 'one size fits all' approach, with interventions not tailored to the needs and preferences of individuals. Therefore, the aim of this study is to evaluate the effectiveness of a personalised intervention programme aimed at improving adherence to oral antidiabetic and/or antihypertensive medication in people with T2DM.

METHODS

A parallel-group randomised controlled trial will be conducted in 40-50 community pharmacies in the Netherlands and the United Kingdom (UK). A total of 300 participants will be included and followed up for a period of 6 months. Participants will be people with T2DM identified as non-adherent to oral antidiabetic and/or antihypertensive medication, aged 35-75 years and mobile phone users. The intervention group will receive a personalised intervention programme that is based on one or more of the participants' pre-defined non-adherence profile(s), namely (I) Knowledge and perceptions, (II) Practical problems, (III) Side effects and (IV) Negative mood and beliefs. The intervention comprises of one or more supporting modules, namely (I) Brief messaging, (II) Clinical medication review, (III) Medication schedule, (IV) Reminding messaging, (V) Medication dispensing systems, (VI) Smart messaging, (VII) Referral to general practitioner and (VIII) Unguided web-based Self Help Application for low mood. The control group will receive usual care including access to a publicly available informative diabetes website. The primary study outcome is medication adherence measured with a telephone pill count. Secondary outcomes are systolic blood pressure, HbA1c level, self-reported medication adherence, attitude and beliefs toward medication, satisfaction with diabetes treatment, health status and medical consumption and productivity cost. In addition, a process evaluation will be undertaken to establish the fidelity, reach and the extent to which intervention delivery is normalised in the daily practice of community pharmacy teams.

DISCUSSION

The study can lead to a personalised intervention programme that improves medication adherence in people with T2DM that are non-adherent to oral antidiabetic and/or antihypertensive medication.

TRIAL REGISTRATION

Dutch Trial Register, Trial NL8747 , registered 02 July, 2020; ISRCTN Registry, ISRCTN36009809 , registered 05 February, 2020.

Content Validity of Patient-Reported Outcome Measures Developed for Assessing Health-Related Quality of Life in People with Type 2 Diabetes Mellitus: a Systematic Review

PURPOSE OF REVIEW

We aimed to systematically evaluate the content validity of patient-reported outcome measures (PROMs) specifically developed to measure (aspects of) health-related quality of life (HRQOL) in people with type 2 diabetes. A systematic review was performed in PubMed and Embase of PROMs measuring perceived symptoms, physical function, mental function, social function/participation, and general health perceptions, and that were validated to at least some extent. Content validity (relevance, comprehensiveness, and comprehensibility) was evaluated using COSMIN methodology.

RECENT FINDINGS

We identified 54 (different versions of) PROMs, containing 150 subscales. We found evidence for sufficient content validity for only 41/150 (27%) (subscales of) PROMs. The quality of evidence was generally very low. We found 66 out of 150 (44%) (subscales of) PROMs with evidence for either insufficient relevance, insufficient comprehensiveness, or insufficient comprehensibility. For measuring diabetes-specific symptoms, physical function, mental function, social function/participation, and general health perceptions, we identified one to 11 (subscales of) PROMs with sufficient content validity, although quality of the evidence was generally low. For measuring depressive symptoms, no PROM with sufficient content validity was identified. For each aspect of HRQL, we found at least one PROM with sufficient content validity, except for depressive symptoms. The quality of the evidence was mostly very low.

All together: Integrated care for youth with type 1 diabetes

OBJECTIVE

We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional well-being, and depression.

RESEARCH DESIGN AND METHODS

The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods.

RESULTS

There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team.

CONCLUSION

The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

Feasibility and user experience of the unguided web-based self-help app 'MyDiaMate' aimed to prevent and reduce psychological distress and fatigue in adults with diabetes

INTRODUCTION

Psychological distress and fatigue are common in persons with diabetes, adversely affecting quality of life and complicating diabetes self-management. Offering diabetes-specific self-guided cognitive behavioral therapy (CBT) may be helpful for persons with diabetes and mild symptoms of psychological distress and fatigue. We are the first to test the feasibility and user experiences of a web-based self-help app called 'MyDiaMate' in adults with type 1 and type 2 diabetes.

METHODS AND MATERIALS

MyDiaMate was developed in close collaboration with persons with diabetes and professionals, building on elements from existing (guided) diabetes-specific CBT interventions. The study was advertised, offering free access to the app for adults with diabetes for a period of three months. Feasibility and user experiences were tested in a non-randomized study with pre- and post- measurements and interviews in a small sample.. In addition usage of the app was studied using log-data..

RESULTS

In total N = 55 adults with diabetes signed up for the study. Mean age was M = 42.7 (SD = 15.6), mostly women (n = 39, 70.9%), higher educated (n = 36, 65.5%), and diagnosed with type 1 diabetes (n = 37, 67.3%). About half reported current or a history of psychological complaints. All the participants completed baseline assessments, and n = 32 participants (58%) completed the follow-up questionnaire. Main reasons for participating in the study were: to preserve or improve mental fitness (40.6%), curiosity (25.0%) and wanting to contribute to research (34.4%). No major technical issues were encountered in accessing or using the app. The app was opened at least once by n = 51 participants, median use of the modules was 28 min (1-80) within a period of 1 to 92 days (median = 10). Almost all participants (n = 50, 98.0%) opened the basic module 'Diabetes in balance', of whom 32 (62.7%) completed this module. 'My mood' and 'My energy' were opened by n = 40 (78.4%) and n = 32 (62.7%) participants, respectively, and completed by n = 21 (52.5%) and n = 9 (28.1%) of the participants. Of all participants, 40.6% would recommend the app to others living with diabetes.

CONCLUSIONS

This study confirmed the feasibility of MyDiaMate as a diabetes-specific self-guided app for adults wishing to preserve or improve their psychological health. While user experiences were overall positive, further tailoring the content to individual needs and preferences could enhance uptake, usage and appreciation. Future research should explore its effectiveness in a randomized controlled trial.

Health-related quality of life in parents and partners of people with type 1 diabetes: Development and validation of type 1 diabetes and life (T1DAL) measures

INTRODUCTION

Despite the significant impact of type 1 diabetes (T1D) on family, few instruments are available to assess health-related quality of life (HRQOL) among family members of people with T1D. This study aimed to develop and evaluate the psychometric properties of new measures of diabetes-specific HRQOL for parents and partners of people with T1D. We report on the multistep development and validation process for the self-report Type 1 Diabetes and Life (T1DAL) measures, with versions for parents of youth age <8, 8-11, 12-17, and 18-25 years, and for partners of people age ≥18 years with T1D.

METHOD

First, we conducted qualitative interviews (total parents/partners n = 38) to develop draft measures and piloted them (total n = 20). Next, we tested the measures' psychometric properties. Participants (total across versions n = 813) at six T1D Exchange Clinic Network sites completed the appropriate T1DAL measure and validated measures of related constructs. We then reduced each T1DAL measure to 20-30 items in length based on psychometric data and participant feedback. Eleven participants reviewed the final measures via cognitive debriefing.

RESULTS

The T1DAL measures for parents and partners demonstrated good internal consistency (α = .80-.88) and test-retest reliability (r = .73-.86). Correlations with measures of general quality of life, generic and diabetes-specific HRQOL, and diabetes burden demonstrated construct validity. Factor analyses identified 3-4 subscales/measure. Participants reported being satisfied with the shortened measures, which took 5-10 minutes to complete.

DISCUSSION

The new T1DAL measures for parents and partners of people with T1D are reliable, valid, and ready for use in research and clinical settings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Executive function mediates the link between externalizing behavior and HbA1c in children and adolescents with type 1 diabetes: A cross-national investigation

OBJECTIVE

Externalizing behavior (i.e., conduct problems, hyperactivity) and executive function (EF) problems in children and adolescents with type 1 diabetes (T1D) have been associated with worse diabetes-related and psychosocial outcomes but have not been examined in relationship to each other. We aimed to examine whether externalizing behavior is associated with HbA1c and whether this relationship is mediated by EF problems, specifically metacognition (i.e., ability to initiate, plan, organize and monitor behavior) and behavioral regulation (i.e., impulse control, regulation of emotion and behavior).

RESEARCH DESIGN AND METHODS

Cohorts of Belgian and Dutch parents of children and adolescents (6-18 years) with T1D filled out questionnaires on externalizing behavior (Strengths and Difficulties Questionnaire; SDQ) and EF (Behavior Rating Inventory of Executive Function; BRIEF) composite scales. Treating physicians collected HbA1c values. Mediation analyses were performed separately for the BRIEF composite Metacognition and Behavior Regulation scales, correcting for age, sex and diabetes duration.

RESULTS

The 335 parents of children and adolescents with T1D (mean age 12.3 ± 2.8 SD; mean HbA1c 7.6% ± 1.1 SD [60 mmol/mol ± 12.0 SD]; mean diabetes duration 5.3 ± 3.6 SD; 49.6% female) participated. Analyses showed that the association between externalizing behavior and HbA1c is mediated by metacognition (ab path Point estimate = 0.05 BCa CI 95% 0.02-0.08), and not behavioral regulation.

CONCLUSIONS

Results uncovered the influence externalizing behavior may have on EF problems in the metacognition domain, which in turn seem to influence HbA1c. Clinicians should be mindful of these EF problems when working with children and adolescents displaying externalizing behavior, and not only target behavioral but also cognitive processes.

Design and psychometrics for new measures of health-related quality of life in adults with type 1 diabetes: Type 1 Diabetes and Life (T1DAL)

AIMS

To use a three-phase process to develop and validate new self-report measures of diabetes-specific health-related quality of life (HRQOL) for adults with type 1 diabetes. We report on four versions of the Type 1 Diabetes and Life (T1DAL) measure for people age 18-25, 26-45, 46-60, and over 60 years.

METHODS

We first conducted qualitative interviews to guide measure creation, then piloted the draft measures. We evaluated psychometric properties at six T1D Exchange Clinic Network sites via completion of T1DAL and validated measures of related constructs. Participants completed the T1DAL again in 4-6 weeks. We used psychometric data to reduce each measure to 23-27 items in length. Finally, we obtained participant feedback on the final measures.

RESULTS

The T1DAL-Adult measures demonstrated good internal consistency (α = 0.85-0.88) and test-retest reliability (r = 0.77-0.87). Significant correlations with measures of general quality of life, generic and diabetes-specific HRQOL, diabetes burden, self-management, and glycemic control demonstrated validity. Factor analyses yielded 4-5 subscales per measure. Participants were satisfied with the final measures and reported they took 5-10 min to complete.

CONCLUSIONS

The strong psychometric properties of the newly developed self-report T1DAL measures for adults with type 1 diabetes make them appropriate for use in clinical research and care.

Glucose variability and mood in adults with diabetes: A systematic review

Aims

To systematically review the literature regarding the association between glucose variability (GV) and mood in adults with diabetes, appraise the used methods and make suggestions for future research.

Methods

A systematic review of literature published up to May 2019 was performed. Abstracts and full texts were screened independently in duplicate. Experimental and observational studies reporting the association between GV and mood in adults with type 1 diabetes or type 2 diabetes were evaluated. A descriptive analysis of the extracted data was conducted, along with a quality assessment.

Results

Out of the 2.316 studies screened, eight studies met our criteria. Studies used a variety of measures and metrics to determine GV and mood. Four studies used continuous glucose monitoring (CGM). An association between GV and mood was found in four studies when correlating either postprandial glucose rate of increase with current mood or multiday GV with mood measured retrospectively. The other four studies did not find any association.

Conclusions

There is no clear empirical support for a link between GV and mood in adults with type 1 and type 2 diabetes. More rigorous research is warranted using CGM and ecological momentary assessment of mood to assess if and under what conditions an association between GV and mood exists.

Assessing Health-Related Quality of Life in Children and Adolescents with Diabetes: Development and Psychometrics of the Type 1 Diabetes and Life (T1DAL) Measures

OBJECTIVE

To develop and validate new measures of diabetes-specific health-related quality of life (HRQOL) for people with type 1 diabetes (T1D) that are brief, developmentally appropriate, and usable in clinical research and care. Here we report on the phases of developing and validating the self-report Type 1 Diabetes and Life (T1DAL) measures for children (age 8-11) and adolescents (age 12-17).

METHODS

Measure development included qualitative interviews with youth and parents (n = 16 dyads) followed by piloting draft measures and conducting cognitive debriefing with youth (n = 9) to refine the measures. To evaluate the psychometric properties, children (n = 194) and adolescents (n = 257) at three T1D Exchange Clinic Network sites completed the age-appropriate T1DAL measure and previously validated questionnaires measuring related constructs. Using psychometric data, the investigators reduced the length of each T1DAL measure to 21 and 23 items, respectively, and conducted a final round of cognitive debriefing with six children and adolescents.

RESULTS

The T1DAL measures for children and adolescents demonstrated good internal consistency (α = 0.84 and 0.89, respectively) and test-retest reliability (r = 0.78 and 0.80, respectively). Significant correlations between the T1DAL scores and measures of general quality of life, generic and diabetes-specific HRQOL, diabetes burden, and diabetes strengths demonstrated construct validity. Correlations with measures of self-management (child and adolescent) and glycemic control (adolescent only) demonstrated criterion validity. Factor analyses indicated four developmentally specific subscales per measure. Participants reported satisfaction with the measures.

CONCLUSIONS

The new T1DAL measures for children and adolescents with T1D are reliable, valid, and suitable for use in care settings and clinical research.

Using Person-Reported Outcomes (PROs) to Motivate Young People with Diabetes

PURPOSE OF REVIEW

This manuscript describes how person-reported outcomes (PROs) can be utilized in care for young people with diabetes in the context of motivation.

RECENT FINDINGS

The use of person-reported outcome measures (PROMS) in clinical care is feasible and acceptable, and helps focus the clinical encounter on life domains important to the person with diabetes. Results with regard to impact on self-management and glycemic outcomes are limited. Motivation is an important factor for self-management. Based on self-determination theory, autonomy-supportive, person-centered, and collaborative communication by diabetes care providers is associated with better outcomes. PROMs can facilitate this conversation. Understanding of youth motivation for maintaining or improving self-management behaviors requires a person-centered approach. PROMs can be used to facilitate an autonomy-supportive and person-centered conversation in clinical care. Training diabetes care providers in autonomy-supportive, person-centered conversation skills to discuss PROs might help to tap into youth's motivation, but further research is needed.

Comparing the EQ-5D-5L crosswalks and value sets for England, the Netherlands and Spain: Exploring their impact on cost-utility results

This study compares the five-level EuroQol five-dimension questionnaire (EQ-5D-5L) crosswalks and the 5L value sets for England, the Netherlands, and Spain and explores the implication of using one or the other for the results of cost-utility analyses. Data from two randomized controlled trials in depression and diabetes were used. Utility value distributions were compared, and mean differences in utility values between the EQ-5D-5L crosswalk and the 5L value set were described by country. Quality-adjusted life years (QALYs) were calculated using the area-under-the-curve method. Incremental cost-effectiveness ratios (ICERs) were calculated, and uncertainty around ICERs was estimated using bootstrapping and graphically shown in cost-effectiveness acceptability curves. For all countries investigated, utility value distributions differed between the EQ-5D-5L crosswalk and 5L value set. In both case studies, mean utility values were lower for the EQ-5D-5L crosswalk compared with the 5L value set in England and Spain, but higher in the Netherlands. However, these differences in utility values did not translate into relevant differences across utility estimation methods in incremental QALYs and the interventions' probability of cost-effectiveness. Thus, our results suggest that EQ-5D-5L crosswalks and 5L value sets can be used interchangeably in patients affected by mild or moderate conditions. Further research is needed to establish whether these findings are generalizable to economic evaluations among severely ill patients.

Improving interpretability of individual Diabetes Symptom Checklist-Revised (DSC-R) scores: the role of patient characteristics

INTRODUCTION

The Diabetes Symptom Checklist-Revised (DSC-R) is a well-validated patient-reported outcome designed to assess symptom burden in persons with type 2 diabetes mellitus (T2DM) across eight domains. The DSC-R has so far primarily been used in research settings. With the aim to make the DSC-R applicable in clinical practice by improving its interpretability, we sought to identify patient characteristics associated with DSC-R (domain) scores as a first initiative toward reference values.

RESEARCH DESIGN AND METHODS

We used baseline data from two large observational studies to select patient characteristics significantly associated with DSC-R domain and total scores. Multivariable Tobit analyses with the backward procedure per (domain) score were performed.

RESULTS

Data from 1531 participants with T2DM were included. On a 0-100 scale, the median DSC-R total score was 15.88 (7.06-29.41), with domain scores ranging from 5.00 (0.00-22.50) (pain) to 35.00 (10.00-60.00) (fatigue). Low well-being status was most profoundly associated with higher scores across all domains. Persons with one or more complication, as well as one or more symptomatic hypoglycemic episode during the past 3 months, scored higher on (almost) all domains and the total scale.

CONCLUSIONS

Complications, symptomatic hypoglycemia, and low well-being are important characteristics to take into account when using the DSC-R in individual patients. Further validation of our findings is warranted in diverse patient populations.

"Let's talk about it" The role of parental communication in adolescents' motivation to adhere to treatment recommendations for type 1 diabetes

OBJECTIVE

Grounded in Self-Determination Theory, this study examines the role of parental expectations and communication style (ie, in an autonomy-supportive vs controlling way) in the prediction of adolescent motivation (ie, internalization or defiance) to adhere to self-management for type 1 diabetes.

METHODS

Structural Equation Modeling was used in a cross-sectional, multi-informant study of 129 adolescents (Mage = 14.43; 54.4% girls), 110 mothers, and 98 fathers. Adolescents reported on self-motivation, treatment adherence, and parental expectations and communication styles; parents reported on their own expectations, communication style, and perceptions of adolescent treatment adherence. Medical record review provided HbA1c values.

RESULTS

Across adolescent and parent reports, parental communication of diabetes-specific expectations and an autonomy-supportive style of communicating expectations related positively to adolescents' internalization of diabetes self-management and negatively to defiance against diabetes self-management. In contrast, a controlling parental communication style showed the opposite patterns of associations. Higher adolescent defiance was related to poorer treatment adherence and worse glycemic control.

CONCLUSIONS

Parental communication styles related to adolescent motivation, which in turn, related to adolescent treatment adherence and glycemic control. Future longitudinal research can address the long-term impact of both maternal and paternal communication styles on adolescent motivation to adhere to treatment and their subsequent glycemic control.

Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review

BACKGROUND

Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient's particular situation. Six SDM key elements can be identified: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences, and making the decision. The International Patient Decision Aid Standards (IPDAS) require that a decision aid (DA) support these key elements. Yet, the extent to which DAs support these six key SDM elements and how this relates to their impact remain unknown.

METHODS

We searched bibliographic databases (from inception until November 2017), reference lists of included studies, trial registries, and experts for randomized controlled trials of DAs in patients with cardiovascular, or chronic respiratory conditions or diabetes. Reviewers worked in duplicate and independently selected studies for inclusion, extracted trial, and DA characteristics, and evaluated the quality of each trial.

RESULTS

DAs most commonly clarified options (20 of 20; 100%) and discussed their harms and benefits (18 of 20; 90%; unclear in two DAs); all six elements were clearly supported in 4 DAs (20%). We found no association between the presence of these elements and SDM outcomes.

CONCLUSIONS

DAs for selected chronic conditions are mostly designed to transfer information about options and their harms and benefits. The extent to which their support of SDM key elements relates to their impact on SDM outcomes could not be ascertained.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42016050320 .

Positive Well-Being in Youth With Type 1 Diabetes During Early Adolescence

Developmental shifts during early adolescence relate to type 1 diabetes (T1D) self-management, increased risk of emotional distress, and worsening health status. Less is known about positive experiences related to T1D. This study evaluated associations of positive well-being (PWB) with diabetes burden, self-management, and glycemic control. Youth (N = 55, age = 12-13 years; X̄ age = 12.75 + 0.56 years, 50.9% male, 38.2% non-Caucasian) reported PWB, depressive symptoms, and diabetes burden. Parents reported on overall T1D adherence. Adherence behaviors and glycemic control were assessed objectively. Higher PWB correlated with lower depressive symptoms (r s = -.45), less diabetes burden (r s = -.48), and better glycemic control (r s = -.43), all p < .01. When controlling for diabetes duration, higher PWB correlated with lower depressive symptoms and better glycemic control. PWB was not related to demographics or adherence. Initial exploration suggests PWB is related to key diabetes constructs, and maybe valuable to consider along with efforts to support youth with T1D during a vulnerable developmental period.

Child and parental executive functioning in type 1 diabetes: Their unique and interactive role toward treatment adherence and glycemic control

OBJECTIVE

Managing type 1 diabetes (T1D) requires the ability to make complex and critical decisions regarding treatment, to execute complex tasks accurately, and to make adjustments when problems arise. This requires effective neuropsychological competences of patients and their families, especially in the domain of executive functioning (EF): the ability to self-monitor, plan, solve problems, and set priorities. Previous research focused mainly on child EF, neglecting the impact of parental EF. This study included both mothers and fathers and examined associations between child and parental EF and treatment adherence to T1D in a broad age range of patients.

METHODS

Parents of 270 patients (6-18 years) with T1D (mean age 12.7 years; 52.6% female) were included. Mothers (N = 232) and fathers (N = 168) completed questionnaires on child and parental EF and on treatment adherence. Analyses examined the associations linking child and parental EF to treatment adherence and glycemic control (and potential moderation effects in these associations) using hierarchical linear regression.

RESULTS

Child EF problems were negatively associated with treatment adherence. As an indication of moderation, this effect was stronger in older children. Better treatment adherence and glycemic control were reported when both child and parent showed less EF problems. Effects were more pronounced in mothers than in fathers.

CONCLUSIONS

This study demonstrated a significant interplay between child and parental EF in the association with treatment adherence and glycemic control. Researchers and clinicians should remain attentive toward the role of neuropsychological concepts such as EF. Implementation in clinical practice seems meaningful.

Improved diabetes medication convenience and satisfaction in persons with type 2 diabetes after switching to insulin glargine 300 U/mL: results of the observational OPTIN-D study

OBJECTIVE

Insulin glargine 300 (Gla-300) provides less hypoglycemia risk and more flexibility in injection time. The extent to which these effects translate into improved patient-reported outcomes (PROs) is unknown, and is the subject of this observational study.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes treated with basal insulin for at least 6 months initiating Gla-300 were included. Data were collected at baseline (start Gla-300) and at 3-month and 6-month follow-up. Patients and physicians gave reasons for switching to Gla-300 at baseline and the extent to which Gla-300 fulfilled their expectations at 6 months. Mixed model analyses examined PRO changes over time, with emotional well-being (WHO-5 Well-Being Index) as the primary outcome. The secondary outcomes were hypoglycemia incidence, hemoglobin A1c (HbA1c), hypoglycemia worries (worry subscale of the Hypoglycemia Fear Survey), diabetes distress (short form of the Dutch version of the Problem Areas In Diabetes Scale), diabetes medication convenience (Diabetes Medication System Rating Questionnaire (DMSRQ)), sleep quality and duration (Pittsburgh Sleep Quality Index), and adherence (Summary of Diabetes Self-Care Activities).

RESULTS

162 patients participated: 53.70% were men, the mean age was 65.54 years (9.05), baseline mean HbA1c was 7.87% (1.15) (62.48 mmol/mol (12.61)), and mean diabetes duration was 15.14 years (6.65). Mean WHO-5 Well-Being Index scores improved non-significantly from 61.94 (19.52) at baseline (T0) to 63.83 (19.67) at 6 months (T2). Mean DMSRQ scores improved significantly from 32.96 (9.02) (T0) to 36.70 (8.85) (T2) (p<0.001). Dose (less volume) was a switching reason in 69.60% of patients and 63% of physicians, and flexibility in 33.30% and 24.70%, respectively. Gla-300 fulfilled the expectations or even better than expected in 92.30% of patients and 88.90% of physicians.

CONCLUSION

In a relatively well-controlled sample of adults with type 2 diabetes, switching to Gla-300 improves diabetes medication convenience.

Continuous Glucose Monitoring in Patients with Type 1 Diabetes and Impaired Awareness of Hypoglycemia: Also Effective in Patients with Psychological Distress?

The aim of this study was to evaluate whether psychological distress modifies the effect of continuous glucose monitoring (CGM) in patients with type 1 diabetes (T1D) and impaired awareness of hypoglycemia. Fifty-two patients with T1D and impaired awareness of hypoglycemia participated in an earlier reported randomized crossover trial with two 16-week intervention periods comparing CGM with self-monitoring of blood glucose (SMBG). During the CGM phase, time spent in euglycemia (4-10 mmol/L), the primary outcome, was 9.6% higher compared with the SMBG phase (P < 0.0001). Psychological distress was operationalized as low emotional well-being (World Health Organization Well-being Index 5 [WHO-5] < 50), high diabetes-related distress (Problem Areas in Diabetes 5 [PAID-5] ≥ 8), and/or high fear of hypoglycemia (Hypoglycemia Fear Survey [HFS] Worry > mean HFS Worry score +1 standard deviation). Modifying effects were assessed by analyzing psychological distress score × intervention-interaction effects. Results showed that both the low emotional well-being group and normal emotional well-being group had equal glycemic outcomes during the CGM phase. High diabetes distress and elevated fear of hypoglycemia did not result in significant interaction effects for glycemic outcomes. This study demonstrated that CGM is equally effective in terms of glycemic improvements in high versus low distressed patients with T1D and impaired awareness of hypoglycemia.

A systematic review of decision aids that facilitate elements of shared decision-making in chronic illnesses: a review protocol

BACKGROUND

Shared decision-making (SDM) is a patient-centred approach in which clinicians and patients work side-by-side to decide together on the best course of action for each patient's particular situation. Six key elements of SDM can be distinguished: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences and making the decision. Decision aids (DAs) are tools that facilitate SDM. The impact of DAs for chronic illnesses on SDM, clinical and patient reported outcomes remains uncertain.

METHODS

We will perform a systematic review aiming to describe (a) which SDM elements are incorporated in DAs for adult patients with chronic conditions and (b) the effects of DA use on SDM, clinical and patient reported outcomes. This manuscript reports on the protocol for this systematic review. The following databases will be searched for relevant articles: PubMed, Embase, Web of Science, CINAHL and PsycINFO, from their inception to October 2016. We will ascertain ongoing research by querying experts and searching trial registries. To enhance feasibility, we will limit the review to randomized controlled trials (RCTs) including patients with chronic cardiovascular and/or respiratory diseases and/or diabetes. SDM elements incorporated in DAs, DA effects and DA itself will be described.

DISCUSSION

This study will characterize DAs for chronic illness and will provide an overview of their effects on SDM, clinical and patient reported outcomes. We anticipate this review will bring to light knowledge gaps and inform further research into the design and use of DAs for patients with chronic conditions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42016050320 .

Disturbed eating behaviors in adolescents with type 1 diabetes. How to screen for yellow flags in clinical practice?

BACKGROUND

Adolescents with type 1 diabetes are at an increased risk of disturbed eating behaviors (DEBs).

OBJECTIVE

The aims of this study are to (i) explore the prevalence of DEBs and associated 'yellow flags', and (ii) establish concordance between adolescents-parents and adolescents-clinicians with respect to DEBs.

METHODS

Adolescents (11-16 yr) and parents completed questionnaires. A stepwise approach was used to assess DEBs: only adolescents whose answers raised psychological yellow flags for DEBs completed the Diabetes Eating Problems Scale - Revised and questions from the AHEAD study. Parents and clinicians shared their observations regarding possible DEBs. Kruskal-Wallis tests, post hoc Mann-Whitney U test, and chi-squared tests were utilized to examine clinical yellow flags. Cohen's kappa was used to assess concordance.

RESULTS

Of 103 adolescents participated (51.5% girls), answers of 47 (46.5%) raised psychological yellow flags, indicating body and weight concerns. A total of 8% scored above cut-off for DEBs. Clinical yellow flags were elevated glycated hemoglobin A1c (p = 0.004), older age (p = 0.034), dieting frequency (p = 0.001), reduced quality of life (p = 0.007), less diabetes self-confidence (p = 0.015), worsened diabetes management (p < 0.001), and body dissatisfaction (p < 0.001). Body Mass Index (BMI) z-scores and gender were no yellow flags. Concordance between parents and adolescents was slight (k = 0.126 and 0.141), and clinicians and adolescents was fair (k = 0.332).

DISCUSSION

Half of the adolescents reported body and weight concerns, less than 1 in 10 reported DEBs. Screening for yellow flags for DEBs as a part of clinical routine using a stepwise approach and early assistance is recommended to prevent onset or deterioration of DEBs.

Parental Diabetes Behaviors and Distress Are Related to Glycemic Control in Youth with Type 1 Diabetes: Longitudinal Data from the DINO Study

OBJECTIVE

To evaluate (1) the longitudinal relationship between parental well-being and glycemic control in youth with type 1 diabetes and (2) if youth's problem behavior, diabetes parenting behavior, and parental diabetes-distress influence this relationship.

RESEARCH DESIGN AND METHODS

Parents of youth 8-15 yrs (at baseline) (N = 174) participating in the DINO study completed questionnaires at three time waves (1 yr interval). Using generalized estimating equations, the relationship between parental well-being (WHO-5) and youth's HbA1c was examined. Second, relationships between WHO-5, Strength and Difficulties Questionnaire (SDQ), Diabetes Family Behavior Checklist (DFBC), Problem Areas In Diabetes-Parent Revised (PAID-Pr) scores, and HbA1c were analyzed.

RESULTS

Low well-being was reported by 32% of parents. No relationship was found between parents' WHO-5 scores and youth's HbA1c (β = -0.052, p = 0.650). WHO-5 related to SDQ (β = -0.219, p < 0.01), DFBC unsupportive scale (β = -0.174, p < 0.01), and PAID-Pr (β = -0.666, p < 0.01). Both DFBC scales (supportive β = -0.259, p = 0.01; unsupportive β = 0.383, p = 0.017), PAID-Pr (β = 0.276, p < 0.01), and SDQ (β = 0.424, p < 0.01) related to HbA1c.

CONCLUSIONS

Over time, reduced parental well-being relates to increased problem behavior in youth, unsupportive parenting, and parental distress, which negatively associate with HbA1c. More unsupportive diabetes parenting and distress relate to youth's problem behavior.

Effectiveness of HypoAware, a Brief Partly Web-Based Psychoeducational Intervention for Adults With Type 1 and Insulin-Treated Type 2 Diabetes and Problematic Hypoglycemia: A Cluster Randomized Controlled Trial

OBJECTIVE

To establish the effectiveness of a brief, partly web-based group intervention, HypoAware, in patients with problematic hypoglycemia, in terms of the reduction of severe hypoglycemic episodes, impaired hypoglycemia awareness, and worries.

RESEARCH DESIGN AND METHODS

A two-arm, cluster randomized controlled trial was conducted in insulin-treated patients with problematic hypoglycemia in eight Dutch clinics comparing HypoAware with care as usual. Primary outcomes included self-reported severe hypoglycemia, impaired hypoglycemia awareness (Gold score), and worries and distress about hypoglycemia (Hypoglycemia Fear Survey-II/Problem Areas In Diabetes scale hypo-item), assessed at baseline, and at 2, 4, and 6 months of follow-up. We used t tests, nonparametric tests, and intention-to-treat generalized estimation equation (GEE) analyses with linear, logistic, and Poisson or negative binomial models.

RESULTS

We enrolled 137 participants. Adjusted GEE analyses over four time points showed a nonsignificant 33% fewer episodes of severe hypoglycemia in the HypoAware group compared with the control group (relative risk [RR] 0.67 [95% CI 0.39-1.16], P = 0.150); a significant reduced odds of impaired awareness (odds ratio 0.38 [95% CI 0.15-0.95], P = 0.038), a trend toward 20% fewer worries about hypoglycemia (RR 0.80 [95% CI 0.64-1.01], P = 0.059), and a significant 30% less hypo-distress (RR 0.70 [95% CI 0.56-0.88], P = 0.002). Over the 6-month study duration, participants experienced a median of 2.5 events of severe hypoglycemia (interquartile range [IQR] 1-10) in the control condition versus 1 event (IQR 0-6.5) in the HypoAware group (P = 0.030). There was no significant change in HbA_1c level within and between both groups.

CONCLUSIONS

HypoAware resulted in fewer severe hypoglycemic episodes, significantly improved hypoglycemia awareness, and less hypo-distress in comparison with usual care, and deserves further dissemination.

Does low well-being modify the effects of PRISMA (Dutch DESMOND), a structured self-management-education program for people with type 2 diabetes?

AIMS

Diabetes self-management education improves behavioural and clinical outcomes in type 2 diabetes patients, however little is known about the modifying effects of well-being. This is relevant given high prevalence of depression and distress among diabetes patients. We aimed to test whether low well-being modifies the effects of the PRISMA self-management education program (Dutch DESMOND).

METHODS

297 primary care type 2 diabetes patients participated in the PRISMA observational study with a pre-post measurement design. Patients were grouped in low (n=63) and normal well-being (n=234). Low well-being was defined as either low mood (WHO-5<50) and/or high diabetes-distress (PAID-5>8). Outcome measures were: diabetes self-efficacy (CIDS), illness perception (IPQ) and diabetes self-care activities (SDSCA).

RESULTS

Improvements were found in illness perception (b=1.586, p<0.001), general diet (b=1.508, p=0.001), foot care (b=0.678, p=0.037), weekly average diet (b=1.140, p=0.001), creating action plan (b=0.405, p=0.007). Well-being interaction effects were found for general diet (p=0.009), weekly average diet (p=0.022), and creating an action plan (p=0.002).

CONCLUSIONS

PRISMA self-management education seems as effective for people with normal well-being as for people with low well-being. Further research should examine whether addressing mood and diabetes-distress as part of self-management education could reduce attrition and maintain or improve well-being among participants.

Implementation of quality of life monitoring in Dutch routine care of adolescents with type 1 diabetes: appreciated but difficult

OBJECTIVE

Monitoring quality of life (QoL) improves well-being and care satisfaction of adolescents with type 1 diabetes. We set out to evaluate the implementation of the program DAWN (Diabetes Attitudes Wishes and Needs) MIND-Youth (Monitoring Individual Needs in Young People With Diabetes) (DM-Y), in which Dutch adolescents' QoL is assessed with the MIND Youth Questionnaire (MY-Q) and its outcomes are discussed. Successful implementation of DM-Y warrants close study of experienced barriers and facilitators as experienced by diabetes care teams as well as adolescents and parents.

METHODS

The study was conducted in 11 self-selected Dutch pediatric diabetes clinics. A mixed methods approach was used. Ten diabetes teams (26 members) were interviewed; 36 team members, 29 adolescents, and 66 parents completed an online survey.

RESULTS

Two of 10 teams successfully implemented DM-Y. Whereas 92% of teams valued DM-Y as a useful addition to routine care, most clinics were not able to continue because of logistical problems (lack of time and manpower). Still, all teams had the ambition to make DM-Y integral part of routine care in the nearby future. Seventy-nine percentage of the parents and 41% of the adolescents appreciated the usage of MY-Q, same percentage of adolescents neutral.

CONCLUSIONS

DM-Y is highly appreciated by teams, as well as adolescents and parents, but for most clinics it is difficult to implement. More effort should be paid to resolve logistic problems in order to facilitate dissemination of DM-Y in care nationwide.

Low Self-Confidence and Diabetes Mismanagement in Youth with Type 1 Diabetes Mediate the Relationship between Behavioral Problems and Elevated HbA1c

INTRODUCTION

Previous studies indicated an association between behavior problems (internalizing, externalizing) and glycemic control (HbA1c) in youth with type 1 diabetes (T1D). The aim of this study is to examine if this association is mediated by self-confidence and mismanagement of diabetes.

METHODS

Problem behavior was assessed with the Strengths and Difficulties Questionnaire. Mediating variables were assessed using the Confidence in Diabetes Self-Care-Youth and Diabetes Mismanagement Questionnaire. HbA1c was derived from hospital charts. Bootstrap mediation analysis for multiple mediation was utilized.

RESULTS

88 youths with T1D, age 11-15 y, participated. The relation between both overall problem behavior and externalizing behavior problems and HbA1c was mediated through confidence in diabetes self-care and mismanagement (a 1 b 1 + a 2 b 2 path; point estimate = 0.50 BCa CI 95% 0.25-0.85; a 1 b 1 + a 2 b 2 path; point estimate = 0.73 BCa CI 95% 0.36-1.25).

CONCLUSIONS

Increased problem behavior in youth with T1D is associated with elevated HbA1c and mediated by low self-confidence and diabetes mismanagement. Screening for problem behavior and mismanagement and assisting young patients in building confidence seem indicated to optimize glycemic control.

HypoAware-a brief and partly web-based psycho-educational group intervention for adults with type 1 and insulin-treated type 2 diabetes and problematic hypoglycaemia: design of a cost-effectiveness randomised controlled trial

BACKGROUND

Problematic hypoglycaemia is a significant problem among people with insulin-treated type 1 and 2 diabetes mellitus, which adversely affects quality of life and leads to high societal costs. Blood glucose awareness training (BGAT) is a psycho-educational group intervention that has shown to be effective but difficult to implement in clinical practice, due to its demanding nature. The aim of this study is to evaluate the cost-effectiveness of the HypoAware intervention that has its roots in BGAT and helps patients to effectively recognize, treat and prevent hypoglycaemia, while also focussing on the psychosocial consequences of living with the constant risk of hypoglycaemia, both for patients and their significant others.

METHODS/DESIGN

An economic evaluation will be conducted alongside a cluster-randomised controlled trial in eight hospitals in the Netherlands. We aim to include 154 participants who will either receive HypoAware or care as usual. HypoAware consists of three group sessions and is combined with two online modules. The primary clinical outcome is severe hypoglycaemia. Secondary outcomes include mild hypoglycaemia, hypoglycaemia awareness, fear of hypoglycaemia, diabetes distress, anxiety and depression, health-related quality of life, diabetes-specific self-efficacy and HbA1c. Utilities will be measured using the EQ-5D-5 L questionnaire. Costs will be measured from a societal perspective and include health care utilization, medication and lost productivity costs. Measurements will be performed at baseline, 2, 4, and 6 months to compare both groups, and an additional 12 months for the intervention group only. Process outcomes will be gathered after every group meeting via telephone/email contact with health care professionals and via the online environment.

DISCUSSION

HypoAware is expected to significantly reduce episodes of severe hypoglycaemia, with subsequent beneficial effects on psychosocial outcomes and health care costs. When proven cost-effective, HypoAware will be incorporated in the clinical guidelines of Dutch diabetes care.

TRIAL REGISTRATION

Dutch Trial Register NTR4538.

Diabetes IN develOpment (DINO): the bio-psychosocial, family functioning and parental well-being of youth with type 1 diabetes: a longitudinal cohort study design

Background

Strict glycemic control during adolescence decreases the risk of developing complications later in life, even if this level of control is not maintained afterwards. However, the majority of adolescents with type 1 diabetes (T1D) are in poor control and so far medical or psychological interventions have shown limited success. Adolescence is characterized by major biological, psychosocial, cognitive and parent–child relationship changes and the complex interaction between these developmental trajectories, and its impact on health outcomes is still poorly understood. A specific topic of interest in this context is the timing of diagnosis. The longitudinal study DINO (Diabetes IN develOpment) aims to examine:

If and how the onset of T1D before vs. during puberty results in different outcomes of glycemic control, self-management, psychological functioning and diabetes-related quality of life.

The timing of onset of disturbed eating behavior, its risk factors and its prospective course in relation to glycemic and psychological consequences.

If and how the onset of T1D before vs. during puberty results in different family functioning and parental well-being.

If and how the cognitive development of youth with T1D relates to glycemic control and diabetes self-management.

Methods/design

DINO, a longitudinal multi-center cohort study is conducted in youth with T1D in the age range 8–15 years at baseline. Participants will be divided into two subgroups: pre-pubertal and pubertal. Both groups will be followed for 3 years with assessments based on a bio-psychosocial model of diabetes, scheduled at baseline, 12 months, 24 months and 36 months examining the biological, psychosocial -including disturbed eating behaviors- and cognitive development, family functioning and parental well-being.

Discussion

A better understanding of how the different trajectories affect one another will help to gain insight in the protective and risk factors for glycemic outcomes and in who needs which support at what moment in time. First results are expected in 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0400-1) contains supplementary material, which is available to authorized users.

Diabetes risk reduction in overweight first degree relatives of type 2 diabetes patients: effects of a low-intensive lifestyle education program (DiAlert) A randomized controlled trial

OBJECTIVES

To test the efficacy of a low-intensive lifestyle education program (DiAlert) for overweight first degree relatives of type 2 diabetes patients aimed at reducing diabetes risk.

METHODS

Overweight first degree relatives of type 2 diabetes patients were randomly assigned to the DiAlert intervention (N=45) or control group who received leaflets (N=51). DiAlert consists of two group sessions and newsletters. Assessments were scheduled at baseline, three and nine months, with weight loss as primary outcome. Secondary outcomes included anthropometric, metabolic, behavioral and psychological measures. Comparisons were made over time and between groups.

RESULTS

Both groups showed modest weight loss with no difference between randomization groups. However, after DiAlert significantly more participants lost 5% of their weight compared to controls (P=0.03). Significant improvement of waist circumference sustained after 9 months in the intervention group (intervention: -4.33cm, P<0.01/control: -1.25cm, P=0.08). Systolic blood pressure improved within the intervention group (intervention: -8.77mmHg, P<0.01/control: -1.03mmHg, P=0.60). No effect was observed for biomedical and psychosocial outcomes.

CONCLUSIONS

Our low-intensive structured lifestyle education program helps overweight relatives to improve waist circumference and supports relevant weight loss.

PRACTICE IMPLICATIONS

The family approach provides opportunities to reach and engage relatives at risk in diabetes prevention education.

Design of the e-Vita diabetes mellitus study: effects and use of an interactive online care platform in patients with type 2 diabetes (e-VitaDM-1/ZODIAC-40)

Trial registration: NCT01570140.

BACKGROUND

Due to ongoing rise in need for care for people with chronic diseases and lagging increase in number of care providers, alternative forms of care provision and self-management support are needed. Empowering patients through an online care platform could help to improve patients' self-management and reduce the burden on the healthcare system.

METHODS

Access to laboratory results and educational modules on diabetes will be offered through a platform for subjects with type 2 diabetes mellitus treated in primary care. Differences in socio-demographic and clinical characteristics between subjects expressing interest vs. disinterest to use the platform will be explored. Platform usage will be tracked and compared. Patient satisfaction and quality of life will be measured by validated questionnaires and economic analyses will be performed.

DISCUSSION

This study is designed to assess the feasibility of use of an online platform in routine primary healthcare for subjects with type 2 diabetes mellitus in the Netherlands, and to study effects of use of the platform on treatment satisfaction, quality of life and clinical parameters. Although providing access to a online platform is not a novel intervention, usage and effects have not yet been studied in this patient population.

Use of behavioral change techniques in web-based self-management programs for type 2 diabetes patients: systematic review

Background

Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic metabolic disease characterized by hyperglycemia and cardiovascular risks. Without proper treatment, T2DM can lead to long-term complications. Diabetes self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs for T2DM patients can help to successfully improve patient health behaviors and health-related outcomes. Theories can help to specify key determinants of the target behaviors and behavior change strategies required to arrive at the desired health outcomes, which can then be translated into specific behavioral techniques or strategies that patients can learn to apply in their daily life. From previous reviews of a wide range of online diabetes self-management tools and programs, it appears that it is still unclear which behavioral change techniques (BCTs) are primarily used and are most effective when it comes to improving diabetes self-management behaviors and related health outcomes.

Objective

We set out to identify which BCTs are being applied in online self-management programs for T2DM and whether there is indication of their effectiveness in relation to predefined health outcomes.

Methods

Articles were systematically searched and screened on the mentioned use of 40 BCTs, which were then linked to reported statistically significant improvements in study outcomes.

Results

We found 13 randomized controlled trials reporting on 8 online self-management interventions for T2DM. The BCTs used were feedback on performance, providing information on consequences of behavior, barrier identification/problem solving, and self-monitoring of behavior. These BCTs were also linked to positive outcomes for health behavior change, psychological well-being, or clinical parameters.

Conclusions

A relatively small number of theory-based online self-management support programs for T2DM have been reported using only a select number of BCTs. The development of future online self-management interventions should be based on the use of theories and BCTs and should be reported accurately.

Web-based self-management with and without coaching for type 2 diabetes patients in primary care: design of a randomized controlled trial

BACKGROUND

Self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs have the potential of supporting type 2 diabetes patients with managing their diabetes and reducing the workload for the care provider, where the addition of online coaching could improve patient motivation and reduce program attrition. This study aims to test the hypothesis that a web-based self-management program with coaching will prove more effective on improving patient self-management behavior and clinical outcome measures than a web-based self-management program without coaching.

METHODS

The effects of a web-based self-management program with and without coaching will be tested with a nested randomized controlled trial within a healthcare group in the Netherlands. In one year 220 type 2 diabetes patients will be randomized into an intervention group (n = 110) or a control group (n = 110). The control group will receive only the online self-management program. The intervention group will receive the online self-management program and additional online coaching. Participants will be followed for one year, with follow-up measurements at 6 and 12 months.

DISCUSSION

The intervention being tested is set to support type 2 diabetes patients with their diabetes self-management and is expected to have beneficial effects on self-care activities, well being and clinical outcomes. When proven effective this self-management support program could be offered to other health care groups and their type 2 diabetes patients in the Netherlands.

TRIAL REGISTRATION

Nederlands Trial Register NTR4064.

Effect of the Go4it multidisciplinary group treatment for obese adolescents on health related quality of life: a randomised controlled trial

Background

We developed a Dutch outpatient multidisciplinary group treatment (Go4it) for obese adolescents, including cognitive behavioural therapy and education on healthy dietary and physical activity behaviour. This study examined the effect of Go4it on Health Related Quality of Life (HRQoL).

Methods

At our outpatient paediatric obesity clinic, obese adolescents (n = 122, 11–18 years) were randomly assigned to 1) Go4it, 7 sessions with an interval of 2 weeks or 2) current regular care consisting of referral to a dietician in the home care setting (controls). Linear mixed model analysis was performed to evaluate the intervention effects on HRQoL at 6 and 18-month follow-ups. HRQoL indicators included the Child Health Questionnaire, the Paediatric Quality of Life Inventory™ Version 4.0 (PedsQL™4.0), and the Body Esteem Scale (BES).

Results

In total, 95 adolescents (Go4it 57, controls 38) were included in the current analysis with a mean age of 14.5 ± 1.7 and mean BMI-SDS of 2.9 ± 0.5. At baseline, all participants experienced lower levels of physical and psychosocial well-being compared to a normal weight reference group. At the 18 month follow-up, we found small but beneficial intervention effects on all subscales of the PedsQL™4.0 and BES questionnaires. Two subscales improved significantly; i.e., physical health (between group difference 5.4; 95%CI: 0.3; 10.6), and school functioning (between group difference 7.4; 95%CI: 1.6; 13.2).

Conclusion

Obese adolescents experienced lower HRQoL than their healthy peers. The Go4it intervention had small beneficial effects on HRQoL compared to the current regular care practices for obese adolescents.

Trial registration

Netherlands Trial Register: ISRCTN27626398, METC number: 05.134 (WMO, monocenter).

Assessing diabetes-related quality of life of youth with type 1 diabetes in routine clinical care: the MIND Youth Questionnaire (MY-Q)

AIM

It is recommended to assess health-related quality of life (HRQoL) in teenagers with diabetes as part of their ongoing medical care. Here, we describe the development and psychometric evaluation of the Monitoring Individual Needs in Diabetes Youth Questionnaire (MY-Q), a multi-dimensional self-report HRQoL questionnaire designed for use in pediatric diabetes care.

DESIGN AND METHODS

In expert meetings, characteristics and domains of interest were defined. Existing questionnaires were reviewed, topics selected, and new items added, resulting in the 36-item MY-Q. To test face validity, we interviewed 22 teenagers. In addition, 84 teenagers with type 1 diabetes (age 10-18 yr) completed the MY-Q and Pediatric Quality of Life Inventory (PedsQL) generic and diabetes-modules to examine psychometric properties. Hemoglobin A1c (HbA1c) values were obtained by chart audit.

RESULTS

The MY-Q consists of seven subscales (social impact, parents, diabetes control perceptions, responsibility, worries, treatment satisfaction, and body image and eating behavior) as well as general HRQoL and emotional well-being. Cronbach's alpha for the total scale was 0.80. Strong correlations between MY-Q total and PedsQL generic and diabetes-module scores (r = 0.58 and r = 0.71, p < 0.001) confirmed concurrent validity. Higher HbA1c was associated with lower diabetes control perceptions (r = -0.35, p = 0.001), worries (r = -0.24, p = 0.029), and body image and eating behavior (r = -0.26, p = 0.019) scores. Younger age was associated with higher diabetes control perceptions (r = -0.26, p = 0.020) and body image and eating behavior (r = -0.23, p = .038), and lower responsibility (r = 0.25, p = 0.027) scores.

CONCLUSION

The MY-Q is the first HRQoL questionnaire designed for use in clinical care. It has acceptable measurement properties and seems suitable for implementation in routine care of teenagers with diabetes.

Monitoring of Individual Needs in Diabetes (MIND)-2: follow-up data from the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) MIND study

OBJECTIVE

To test the effects of implementing computer-assisted Monitoring of Individual Needs in Diabetes (MIND) in routine diabetes care on psychological status and glycemic control, identify predictors of poor psychological outcomes, and evaluate care providers' experiences.

RESEARCH DESIGN AND METHODS

The MIND procedure was implemented as part of the annual review in diabetes clinics across eight countries in a prospective observational study with a 1-year follow-up. MIND encompasses well-being (World Health Organization Five Well-Being Index [WHO-5]), diabetes-related distress (Problem Areas in Diabetes [PAID]), a Life Event Inventory, and the patient's agenda for their consultation. Medical data and agreed case-management actions were retrieved from the charts.

RESULTS

Of the total 1,567 patients, 891 patients (57%) were monitored at a 1-year follow-up. Twenty-eight percent of the patients screened positive for depression and/or diabetes distress at baseline and considered cases, 17% of whom were receiving psychological care. Cases were significantly more often female and had type 2 diabetes and worse glycemic control compared with noncases. Clinically relevant improvements in WHO-5 and PAID were observed over time in cases, irrespective of referral (effects sizes 0.59 and 0.48, respectively; P < 0.0001). Glycemic control did not change. Female sex, life events, and concomitant chronic diseases were predictors of poor psychological outcomes. MIND was well received by patients and staff.

CONCLUSIONS

MIND appears suitable for screening and discussion of emotional distress as part of the annual review. Broader dissemination in diabetes care is recommendable, but sustainability will depend on reimbursement and availability of support services.

Monitoring of Individual Needs in Diabetes (MIND)-2: follow-up data from the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) MIND study

OBJECTIVE

To test the effects of implementing computer-assisted Monitoring of Individual Needs in Diabetes (MIND) in routine diabetes care on psychological status and glycemic control, identify predictors of poor psychological outcomes, and evaluate care providers' experiences.

RESEARCH DESIGN AND METHODS

The MIND procedure was implemented as part of the annual review in diabetes clinics across eight countries in a prospective observational study with a 1-year follow-up. MIND encompasses well-being (World Health Organization Five Well-Being Index [WHO-5]), diabetes-related distress (Problem Areas in Diabetes [PAID]), a Life Event Inventory, and the patient's agenda for their consultation. Medical data and agreed case-management actions were retrieved from the charts.

RESULTS

Of the total 1,567 patients, 891 patients (57%) were monitored at a 1-year follow-up. Twenty-eight percent of the patients screened positive for depression and/or diabetes distress at baseline and considered cases, 17% of whom were receiving psychological care. Cases were significantly more often female and had type 2 diabetes and worse glycemic control compared with noncases. Clinically relevant improvements in WHO-5 and PAID were observed over time in cases, irrespective of referral (effects sizes 0.59 and 0.48, respectively; P < 0.0001). Glycemic control did not change. Female sex, life events, and concomitant chronic diseases were predictors of poor psychological outcomes. MIND was well received by patients and staff.

CONCLUSIONS

MIND appears suitable for screening and discussion of emotional distress as part of the annual review. Broader dissemination in diabetes care is recommendable, but sustainability will depend on reimbursement and availability of support services.

DiAlert: a prevention program for overweight first degree relatives of type 2 diabetes patients: results of a pilot study to test feasibility and acceptability

Background

Prevalence of type 2 diabetes mellitus is increasing due to lifestyle changes, particularly affecting those genetically at risk. We developed DiAlert as a targeted group-based intervention aimed to promote intrinsic motivation and action planning for lifestyle changes and weight loss in first degree relatives of patients with type 2 diabetes mellitus.

The main objective of the pilot of the DiAlert intervention was to assess fidelity, feasibility and acceptability prior to starting the randomized controlled trial.

Methods

Individuals with a family history of type 2 diabetes mellitus were self-identified and screened for eligibility. DiAlert consists of two group sessions. Feasibility, fidelity, acceptability and self-reported perceptions and behavioral determinants were evaluated in a pre-post study using questionnaires and observations. Determinants of behavior change were analyzed using paired-samples t tests and Wilcoxon signed rank tests.

Results

DiAlert was delivered to two groups of first degree relatives of patients with type 2 diabetes mellitus (N = 9 and N = 12). Feasibility and fidelity were confirmed. Overall, the DiAlert group sessions were positively evaluated (8.0 on a scale of 1 to 10) by participants. The intervention did not impact perceived susceptibility or worry about personal diabetes risk. Action planning with regard to changing diet and physical activity increased.

Conclusions

DiAlert proved feasible and was well-accepted by participants. Positive trends in action planning indicate increased likelihood of actual behavior change following DiAlert. Testing the effectiveness in a randomized controlled trial is imperative.

Trial registration

Netherlands National Trial Register (NTR): NTR2036